Nicole's clinical presentation and history yield several aspects contributing to a diagnosis of stress urinary incontinence with possible mixed components. Her six full-term vaginal births create obstetrical trauma significance, likely damaging the musculature of the pelvic floor and connective tissue support. Compounding the postmenopausal state is the consequence of estrogen deficiency, resulting in atrophic urethral mucosa and diminished vascularity to the urethral cushion (Harris et al., 2024). Physical examination identifies uterine enlargement, which may suggest pelvic organ prolapse, placing further strain on the urethrovesical angle. When these elements are weighed with her characteristic pattern of symptoms, particularly leak during physical activity versus predominant urgency, strong support for stress-predominant mixed urinary incontinence exists. The absence of significant pertinent neurological history or medications contributing to urinary retention helps to minimize potential etiologies.

There should be thorough education provided to patients taking prescribed oxybutynin 10 mg extended-release about how the medication works and the possible side effects. As an antimuscarinic drug, oxybutynin works by blocking acetylcholine receptors in the detrusor muscle to decrease involuntary contractions (DrugBank, 2025). Nicole should be counselled that, while the medication could potentially improve storage symptoms, the common side effects include xerostomia (which could increase the potential for dental caries), constipation (with an increased need for fiber and fluids), and cognitive effects in geriatric patients. The extended-release formulation includes the benefit of ease of use for patients, but must be swallowed whole. If the oxybutynin is ineffective, mirabegron is an alternative that is a selective beta-3 adrenergic agonist that helps with detrusor relaxation through cAMP channels (Rao, 2022). Blood pressure needs to be monitored at baseline and periodically because of cardiovascular effects. In addition, it may also interact with medications that are metabolized via CYP2D6.

A comprehensive treatment approach should include both pharmacological and non-pharmacological aspects. Supervised pelvic floor muscle training with biofeedback would be especially helpful based on her history of multiple deliveries. Behaviorally, she would benefit from scheduled voiding, fluid management, and weight control. Counseling regarding smoking cessation would still be relevant now that she is not actively using tobacco, as it will have had an ongoing impact on the integrity of her connective tissue (National Spine Health Foundation, 2023). For persistent symptoms, urodynamic studies may allow for a more complete understanding of the pathophysiology behind her symptoms of incontinence and are an inexpensive way to consider advanced treatments such as mid-urethral slings or sacral neuromodulation. Routine follow-up evaluations will monitor her response to treatment and side effects from medications or the need for a referral to a specialist so that Nicole may achieve the best possible quality of life and functional outcome.

References

DrugBank. (2025). Oxybutynin. DrugBank. Retrieved June 3, 2025, from https://go.drugbank.com/drugs/DB01062

Harris, S., Leslie, S. W., & Riggs, J. (2024, June 8). Mixed urinary incontinence. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK559253/

National Spine Health Foundation. (2023). The smoking spine. National Spine Health Foundation. Retrieved June 3, 2025, from https://spinehealth.org/article/the-smoking-spine/

Rao, H. (2022, June 13). Myrbetriq vs. Oxybutynin: Which Is Better for Overactive Bladder? GoodRx. https://www.goodrx.com/conditions/overactive-bladder/myrbetriq-vs-oxybutynin